Key messages
While non-medicine treatments may reduce levels of fear for pregnant women with a high to severe fear of childbirth compared to standard maternity care, the reduction may not represent a meaningful change in their level of fear.Non-medicine treatments probably reduce the number of women who have a caesarean section, where the baby is born surgically. Future research in this area should focus on measuring anxiety levels in women with a high or severe fear of childbirth.
What is fear of childbirth?
Fear of childbirth can range from minor worries and anxieties about giving birth, to a severe fear of childbirth that has a considerable impact on women's lives, causing distress and affecting their mental well-being. A high to severe level of childbirth fear may include extreme levels of fear also known as ‘tocophobia’.
It is normal for pregnant women – particularly first-time mothers – to be anxious, worried or fearful about giving birth. However, some women have high fear related to childbirth and a smaller number have a severe fear of childbirth or ‘tocophobia’. These women:
- may have feelings of isolation, guilt and shame;may choose to terminate a healthy pregnancy, hide a pregnancy or be in denial about a pregnancy;
- may find it difficult to prepare for birth or access pregnancy information because of their fear and may experience problems bonding with their baby;
- may have sleeplessness, nightmares, stomach aches, depression and anxiety that leads to panic attacks.
Women with a high to severe fear of childbirth are more likely to have a planned or emergency caesarean birth, instrumental birth and experience physical effects related to fear, such as prolonged labour. Women with high fear of childbirth without a history of depression are more likely to experience postnatal depression.
How is fear of childbirth treated?
The causes of fear of childbirth are complex and unique for each woman. High to severe fear of childbirth is not recognised or provided for in maternity care in many places in the world. Ways of treating fear of childbirth need to be investigated.
Effective treatments would help women to have confidence in their ability to give birth, give them ways of coping with labour, and empower their decision-making during pregnancy and the birth process.
Treatments aim to provide extra support to women and include:
- sensitive education about the birth process;development of problem-solving skills;
- teaching coping strategies for labour;
- and affirming that negative childbirth events can be managed.
What did we want to find out?
We wanted to find out if non-pharmacological (non-medicine) treatments were better than the standard maternity care provided to pregnant women in terms of:
- reducing women’s level of fear, as measured by a widely-used questionnaire for childbirth fear;
- reducing the number of women having a caesarean birthsection;
- reducing anxiety and depression.
What did we do?
We searched for studies that investigated non-pharmacological treatments aimed at reducing fear of childbirth. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and number of participants.
What did we find?
We found seven studies that involved 1357 pregnant women with a high to severe fear of childbirth including tocophobia. The studies investigated different types of treatment, including:
- psychoeducation (a structured form of education offered to people with mental health conditions);
- cognitive behavioural therapy (a ‘talking therapy’ that aims to help identify and change underlying thought patterns);
- group discussion;peer teaching from other pregnant women;
- and art therapy.
The studies were conducted in five different countries (Australia, Iran, Sweden, Finland and Turkey).
We found that non-pharmacological treatments:
- may reduce fear of childbirth when measured by a widely-used questionnaire, though the reduction may not represent a meaningful change in women's level of fear.
- probably reduce the number of women who go on to have caesarean births (28% of women receiving non-drug treatments had caesarean sections, compared to 40% of women not receiving treatment for fear of childbirth).
- may make little to no difference compared to standard maternity care in terms of women’s depression scores.
What are the limitations of the evidence?
Our confidence in the evidence is limited because the studies were done in such a way that their results may be inaccurate, and because there were low numbers of women in the studies.
How up to date is this evidence?
The evidence in this review is up to date to July 2020.
The effect of non-pharmacological interventions for women with high to severe fear of childbirth in terms of reducing fear is uncertain. Fear of childbirth, as measured by W-DEQ, may be reduced but it is not certain if this represents a meaningful clinical reduction of fear. There may be little or no difference in depression, but there may be a reduction in caesarean section delivery. Future trials should recruit adequate numbers of women and measure birth satisfaction and anxiety.
Many women experience fear of childbirth (FOC). While fears about childbirth may be normal during pregnancy, some women experience high to severe FOC. At the extreme end of the fear spectrum is tocophobia, which is considered a specific condition that may cause distress, affect well-being during pregnancy and impede the transition to parenthood. Various interventions have been trialled, which support women to reduce and manage high to severe FOC, including tocophobia.
To investigate the effectiveness of non-pharmacological interventions for reducing fear of childbirth (FOC) compared with standard maternity care in pregnant women with high to severe FOC, including tocophobia.
In July 2020, we searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies. We contacted researchers of trials which were registered and appeared to be ongoing.
We included randomised clinical trials which recruited pregnant women with high or severe FOC (as defined by the individual trial), for treatment intended to reduce FOC. Two review authors independently screened and selected titles and abstracts for inclusion. We excluded quasi-randomised and cross-over trials.
We used standard methodological approaches as recommended by Cochrane. Two review authors independently extracted data and assessed the studies for risk of bias. A third review author checked the data analysis for accuracy. We used GRADE to assess the certainty of the evidence. The primary outcome was a reduction in FOC. Secondary outcomes were caesarean section, depression, birth preference for caesarean section or spontaneous vaginal delivery, and epidural use.
We included seven trials with a total of 1357 participants. The interventions included psychoeducation, cognitive behavioural therapy, group discussion, peer education and art therapy.
We judged four studies as high or unclear risk of bias in terms of allocation concealment; we judged three studies as high risk in terms of incomplete outcome data; and in all studies, there was a high risk of bias due to lack of blinding. We downgraded the certainty of the evidence due to concerns about risk of bias, imprecision and inconsistency. None of the studies reported data about women's anxiety.
Participating in non-pharmacological interventions may reduce levels of fear of childbirth, as measured by the Wijma Delivery Expectancy Questionnaire (W-DEQ), but the reduction may not be clinically meaningful (mean difference (MD) -7.08, 95% confidence interval (CI) -12.19 to -1.97; 7 studies, 828 women; low-certainty evidence). The W-DEQ tool is scored from 0 to 165 (higher score = greater fear).
Non-pharmacological interventions probably reduce the number of women having a caesarean section (RR 0.70, 95% CI 0.55 to 0.89; 5 studies, 557 women; moderate-certainty evidence).
There may be little to no difference between non-pharmacological interventions and usual care in depression scores measured with the Edinburgh Postnatal Depression Scale (EPDS) (MD 0.09, 95% CI -1.23 to 1.40; 2 studies, 399 women; low-certainty evidence). The EPDS tool is scored from 0 to 30 (higher score = greater depression).
Non-pharmacological interventions probably lead to fewer women preferring a caesarean section (RR 0.37, 95% CI 0.15 to 0.89; 3 studies, 276 women; moderate-certainty evidence).
Non-pharmacological interventions may increase epidural use compared with usual care, but the 95% CI includes the possibility of a slight reduction in epidural use (RR 1.21, 95% CI 0.98 to 1.48; 2 studies, 380 women; low-certainty evidence).